197609902-2-9-2022-31-AS-APAA-CBGSZF-20220209131903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609902
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:19:49 PM

Document Has Been Signed on 02/09/2022 01:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AA AMERICARE HOME CARE		FACILITY NUMBER:	197609902
ADMINISTRATOR:	MANLANGIT, RONNEL		FACILITY TYPE:	740
ADDRESS:	27710 CHERRY CREEK DR		TELEPHONE:	(661) 360-9970
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91354
CAPACITY: 6		CENSUS: 6	DATE:	02/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Ronnel Manlangit, Administrator		TIME COMPLETED:	01:40 PM

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At 11:35am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator, who granted access to the facility. LPA explained the reason for the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/06/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

At 11:40am, LPA conducted a tour of the facility with the Administrator and observed the following:

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Food storage and preparation areas are clean and inaccessible to pests. All knives and sharp objects are locked and inaccessible to residents in care.

Medications are centrally stored and locked in the hallway cabinet and inaccessible to residents in care.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AA AMERICARE HOME CARE	FACILITY NUMBER: 197609902
	VISIT DATE: 02/09/2022

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Bathrooms: The hot water temperature measured within regulation, at 118.7°F. LPA observed appropriate hand washing signs posted in each bathroom, grab bars and non-skid mat.

Outside areas: At approximately, 11:55am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:00pm they were tested and observed to be operational.

Laundry service: At approximately 12:20pm, LPA toured through the laundry area (located in a detached garage) and observed cleaning products/chemicals inaccessible to residents.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500. Annual fees are current. One staff on duty was hired on November 2, 2021 and had not been fingerprint cleared and/or associated with the facility.

Following citations issued for the identified deficiencies pursuant to Title 22 Regulations on LIC809-D.

Exit interview conducted, appeal rights discussed and a copy of this report provided to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/09/2022 01:19 PM - It Cannot Be Edited

Created By: Angela Panushkina On 02/09/2022 at 12:40 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AA AMERICARE HOME CARE	FACILITY NUMBER: 197609902
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(a)

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. One (1) staff who started on November 2, 2021 is not fingerprint cleared and/or associated with the facility, which poses an immediate health, safetyt risk to persons in care.
	POC Due Date: 02/10/2022
	Plan of Correction
1 2 3 4	Administrator has agreed to either have the staff get fingerprinted or submit the request for transfer. Administrator will provide an updated LIC500 to reflect new staff.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Angela Panushkina

LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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